Provider Demographics
NPI:1659340651
Name:BUKALO, NERMINA (MD)
Entity Type:Individual
Prefix:
First Name:NERMINA
Middle Name:
Last Name:BUKALO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-540-6595
Mailing Address - Fax:
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-540-6595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224430208M00000X
CT048166207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2143143Medicaid
I41347Medicare UPIN
MAA3917601Medicare PIN